A systematic review on the use of action research methods in mental health nursing care

Abstract Aims To identify and synthesize evidence on the use of action research methods in mental health nursing care. Design Systematic review. Data Sources CINAHL, Web of Science, PubMed and Scopus databases were searched in January 2021. Review Methods Data were selected using the updated Preferred Reporting Items for Systematic Reviews and Meta‐Analysis framework. Two reviewers independently conducted the study selection, and quality appraisal using Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research, data extraction and data analysis procedures. Results Sixteen studies, half of which used participatory action research, were included in this review. Nurses, along with other stakeholders, were an active part of the action research process. The main topics of interest addressed were categorized as improving the adoption of a person‐centred approach to care and improving decision‐making procedures. The use of action research helped the participants to identify the meaning they attached to the topic of interest to be improved. Moreover, this method helped to identify needs and strategies for improving care. The studies concurred that the use of action research enabled participants to gain awareness, improve attitudes and acquire knowledge. In addition, it enabled participants to gain confidence and security in the group context, as key aspects of their empowerment. Conclusion This review shows the usefulness of action research in any mental health nursing context, contributing to the improvement of care at both the individual and collective levels. Impact This paper demonstrates the use of the action research method in the field of mental health nursing. Its use has improved the clinical practice of nurses as well as that of teams in both community and hospital settings, addressing issues of the person‐centred approach to care and decision‐making procedures.


| INTRODUC TI ON
Action research is a research method that facilitates understanding and improving the world by transforming it (Kemmis & Mctaggart, 2008). Traditionally, this type of approach has been used in the social sciences (Rowell et al., 2017), although in recent years it is also been successfully used internationally in the area of health sciences (Cordeiro & Soares, 2018) and, specifically, in the field of nursing (Effendy et al., 2022). In fact, action research has been shown to be useful for implementing evidence-based practice (Munten et al., 2010) in the area of nursing education or for improving nursing practices in intensive care (Soh et al., 2011). However, no evidence has been found to demonstrate its use and utility, specifically in the field of mental health nursing.

| Background
The action research method relies on inquiry to understand and improve the practices in which one participates and the situations in which one finds oneself (Baum et al., 2006;Kemmis & Mctaggart, 2008). This method includes a family of related approaches that integrate theory and action, approaches that are adapted to the broad and complex contexts and problems addressed (e.g., participatory action research; collaborative action research; cooperative inquiry; feminist participatory action research; rural participatory research and critical participatory action research) (Bradbury, 2015). The action research process consists of a continuous and cyclical interaction where each cycle comprises different stages, such as action, reflection and evaluation (Rowell et al., 2017).
This process enables a better understanding of the nature of practices, their purpose and the necessary conditions to modify these, ultimately resulting in social transformation (Bradbury et al., 2019).
The process can be individual or collective and can modify or produce changes at the level of the individual, collective or organization (Kemmis & Mctaggart, 2008;Rowell et al., 2017).
It is evident that the nature of the action research process contributes to its potential as a method for improving work practices in complex contexts such as healthcare. Thus, there are some reviews in the international literature that have sought to examine the use of action research in the healthcare context. Waterman et al. (2001) conducted a systematic review aimed at identifying research projects in the healthcare field of the UK. The authors concluded that action research had the potential to be useful, not only in areas such as innovation development, healthcare improvement and knowledge development but also to facilitate practitioner understanding and user and professional engagement (Waterman et al., 2001). More recently, Cordeiro and Soares (2018) conducted a scoping review of the international literature to explore how action research had also been applied in studies framed in the general health context. These authors concluded that action research was useful in any context where there were organizational and/or political problems, as well as for addressing gaps in health education at the collective and individual levels (Cordeiro & Soares, 2018).
Specifically, in the area of nursing, nurses are constantly concerned about the difficulties related to the gap between theory, research and practice, therefore, it is necessary to translate these theoretical concepts into practice through research (Greenway et al., 2019). In this sense, Munten et al. (2010) evaluated the use of action research in the implementation of Evidence-Based Practice. The authors concluded that action research was a promising method in what appears to be a useful way to bridge the gap between nursing research and practice (Munten et al., 2010). More specifically, a review was published on the use of action research in the intensive care units. (Soh et al., 2011). In this study, the authors also concluded that action research was a promising method to address the improvement of clinical practice in the intensive care units, although they detected shortcomings in the reviewed studies in terms of clinical outcome assessment (Soh et al., 2011). Likewise, Cusack et al. (2018) studied the value of action research in public health nursing practice, concluding that action research should be the method of choice for examining complex and deeply rooted nursing issues in the profession. In any case, most of the reviews point to the lack of publications about the use of action research and the lack of synthesis about the methodology used (Cordeiro & Soares, 2018;Cusack et al., 2018;Soh et al., 2011;Waterman et al., 2001). This is also the case in mental health nursing. Over the last few years, multiple published studies have used the action research method with different methodological approaches aimed at improving different aspects of clinical practice, such as patient safety (Kanerva et al., 2017), mental health nursing skills (Kelly et al., 2019), self-harm in young people (Bailey et al., 2019) or mental health care programs (Lin et al., 2018;Rezaie & Phillips, 2020). There is great heterogeneity in the studies to date about the description of the methodological approaches and the results obtained (Bailey et al., 2019;Kanerva et al., 2017;Kelly et al., 2019;Rezaie & Phillips, 2020). To our knowledge, no studies have performed a comprehensive analysis and synthesis of the use of action research in mental health nursing. Therefore, it is necessary to compile the available evidence.

| Search methods
The following steps were followed in this review. After a preliminary search to locate any existing or planned systematic reviews on this topic, the first step was a limited search of the PubMed and CINAHL databases using terms related to action research and mental health nursing. An analysis of the text words contained in the title, abstract and index terms used to describe the articles retrieved during the search was then performed. Based on this, an adapted search strategy was designed for all other databases in which searches were performed using database-specific keywords and subject headings, where appropriate. The search strategies can be found in Data S1. c. Types of studies: qualitative primary research that illustrated the action research methodology and methods used, the research process and the results or findings (e.g., knowledge creation, problem-solving, action and others). Studies that reported only one phase or incomplete reports about the action research process were not considered.

| Search outcomes
The preliminary search yielded 538 records. Subsequently, 133 duplicate records were removed, leaving 405 records to be filtered based on their titles and abstracts. In total, 75 full-text articles were assessed for eligibility and subsequently, of which 59 records were excluded. Of those excluded at this stage, 13 did not pertain to mental health nursing, 9 were not directed to the clinical or management setting, 8 did not pertain to the action research method, 26 failed to capture the entire process and three did not present qualitative data. As a result, 16 articles met the criteria and were included in this review. Figure 1 illustrates the search method and the selection process.

| Quality appraisal
Prior to analysis, the selected articles were assessed using the Joanna Briggs Institute Critical Appraisal Checklist (JBI-QARI) to evaluate the quality of individual studies. Two reviewers assessed the studies independently. Disagreements between the two reviewers were resolved by consensus or by consulting a third reviewer when necessary. Although some studies did not report all the items collected in the JBI-QARI, the team decided not to exclude any of them since the purpose of the quality assessment was to follow a systematic and standardized process that would highlight the quality of the available evidence on the study phenomenon (Vanderspank-Wright et al., 2018). The results of the quality assessment are included in Data S2.

| Data abstraction
Initially, a standardized data extraction form was developed that included the following fields: Author, years and source origin, Objective/s, Participants, Concept/Context, Method/Cycles and stages/Collection techniques/Duration, Knowledge building and Social change. Using this form, two authors independently extracted data. Disagreements were resolved by consensus or by consulting a third reviewer.

| Synthesis
The data were analysed using thematic content analysis (Crowe et al., 2015). During the first stage, the text obtained was fragmented into descriptive codes that were assigned according to their semantic content. In the second stage, these codes were grouped into more analytical sub-themes, classifying the codes according to the meaning of the linguistic units and their combinations. Finally, in a third hierarchical stage, the semantic analysis of the previous subthemes was considered, and the codes were classified deductively according to the research questions of the study.

| Characteristics of included studies
The characteristics of the 16 included studies are shown in Table 1. Many of the included studies were conducted in the United Kingdom (k = 6), followed by Australia (k = 2), whereas only one study was included from the following countries: USA, Canada, Ireland, Norway, Sweden, Finland, Spain and Brazil. About the setting in which the studies were carried out, nine were con- in only five studies (Chambers et al., 2013;Chandley et al., 2014;Kidd et al., 2015;Larkin et al., 2015;Onnela et al., 2014). As for the number of participants, this ranged from eight to 45 people in most studies. However, one study mentions the collaboration of over 150 people (Larkin et al., 2015), whereas two of the studies did not specify the number of participants (Hyde et al., 2009;Onnela et al., 2014).

Concept/context Method/cycles and stages/ collection techniques/duration
Concerning the research methods, in all 16 studies group meetings were held in the form of focus groups, workshops and other denominations. However, in four of the studies, interviews were also conducted (Chambers et al., 2013;Clements, 2012;Hutchinson & Lovell, 2013;Larkin et al., 2015) and in two cases reflective journals were used (Moreno-Poyato et al., 2019;Onnela et al., 2014). Other data collection methods and techniques used included photographs and text pieces (Clements, 2012) or observations and field notes (Salzmann-Erikson, 2017).

| Topics of interest for improving mental health nursing care through action research
Two categories were identified: improving the adoption of a person-centred approach to care and improving decision-making procedures ( Figure 2). The category improving the adoption of a person-centred approach to care included topics of studies that aimed to improve care from the people's experience. In this category, recovery-focused care was the most addressed topic (Chandley et al., 2014;Clements, 2012;Kidd et al., 2015;Lange, 2011). For example, in the study by Kidd et al. (2015), systemic barriers in the recovery process were identified by people with experience in providing and receiving mental health services. Another topic of interest was to improve care by understanding the lived experience of service users (Chambers et al., 2013;Hutchinson & Lovell, 2013;Larkin et al., 2015). In this regard, the study by Hutchinson and Lovell (2013) (Borg et al., 2010) and the promotion of mental health in the school setting (Onnela et al., 2014). The category improving decision-making procedures included those topics that sought to improve more specific aspects of mental health care and that responded to the attempt to structure and operationalize procedures for decision-making. In this sense, risk management and assessment of mental health were dealt with in two studies (Crouche & Williamson, 2013;Vantil et al., 2020). Here, the con-

| Action research as a source of knowledge in mental health nursing
In all the studies included in the review, it was possible to clearly identify the knowledge generated. In this regard, the first aspect highlighted in all the articles was that the method made it possible to identify the meaning that the participants gave to the study phenomenon to be improved.

| DISCUSS ION
The purpose of this review was to locate and describe the available evidence related to the use of the action research method in the context of mental health nursing. First, it should be noted that it is a method used to improve aspects related to mental health nursing in both inpatient and community care settings. These findings confirm that action research is useful in any context that aims to improve aspects of health (Cordeiro & Soares, 2018). In addition, it is impor-  From a methodological perspective, it is important to emphasize that although there are different approaches to action research (Rowell et al., 2017), the results of the review indicate that in the field of mental health nursing the most commonly used method is Participatory Action Research. This may be due to the need to work in a participatory fashion, with researchers and stakeholders side by side to address a shared concern which is the driver of the process of change (Kemmis & Mctaggart, 2008). Another outstanding aspect of the results from a methodological point of view was that most of the studies described the cyclical designs used and this made it possible to elaborate a classification of the common stages identified.
However, over one-third of the studies did not specifically describe the cyclical process of the research, whereas some did so in a vague manner, although one of the characteristics of action research is the cyclical nature of the design and process (Casey et al., 2022;Rowell et al., 2017). This finding may explain why, in many of the studies, the results related to the change produced were not clearly identified. In this sense, the lack of description of the stages of action research is an important limitation for assessing the quality of the study report (Casey et al., 2022;Waterman et al., 2001).
The results indicate two major foci for which the action research method has been used in the area of mental health nursing: improving person-centred models of care and improving decision-making procedures. As in other contexts of nursing practice, heterogeneous group participation allows issues of collective concern to be addressed (Cordeiro & Soares, 2018;Cusack et al., 2018), whether it deals with issues related to the care model (Blackwell et al., 2017;Rönnerhag et al., 2019), or if it focuses on improving more specific aspects related to day-to-day decision making (Cerulus et al., 2021;Jokiniemi et al., 2021).
As a source of knowledge, the results of the review point to the usefulness of action research for exploring the meaning of the phenomenon of interest, making it easier for participants to identify what they need to improve and how they can improve it more efficiently (Casey et al., 2022). Thus, action research is a driver for change and improvement in the practice of mental health nurses.
As in other nursing contexts, the findings point to the importance of awareness as a starting point for change (Bekkema et al., 2021;Cusack et al., 2018). This awareness allows the participants to improve their attitude and knowledge about the phenomenon of concern (Tolosa-Merlos et al., 2021). This, together with the support received from the group, improves team relations, increasing motivation and satisfaction in the work environment (Afshar et al., 2020;Chen et al., 2021). Throughout the process, participants gain confidence and security, key aspects for the empowerment of participants (Alomari et al., 2020;Bekkema et al., 2021;Cusack et al., 2018).

| CON CLUS ION
This review has identified and synthesized the available evidence on the use of action research in the context of mental health nursing.
The findings demonstrate that Participatory Action Research is the most widely used action research method and that it is useful for enhancing models of care and improving decision-making procedures, both in the hospital and community settings. Action research can improve aspects of nursing practice and team dynamics. However, it should be noted that the quality assessment of action research articles is complex and requires further research.
In light of the findings of this review, three key points are identified to improve the effectiveness and quality of the use of action research on mental health nursing care: • The perspective of different stakeholders should be incorporated throughout the research process, from project design to the reporting of results. Action research includes the participation of different stakeholders and, therefore, incorporates a collaborative approach both in the identification of the problem and in the actions to foster change. In this sense, it allows all stakeholders to become aware of the issue of interest, directly applying knowledge in practice and obtaining satisfaction and empowerment.
However, still, in the context of mental health nursing, stakeholders are not representatively included in all projects and all their phases.
• It is necessary to provide a detailed description of the cycles and stages of the whole process, together with the objectives to be achieved for each of them. The use of action research, as a method of a cyclical and transformative nature, requires that special attention be paid not only to the end results of the method but also to the results produced in the process. It is important that researchers adequately describe both the stepwise design carried out and the results obtained during the process.
• Clear reporting is warranted on the knowledge generated and the change produced throughout the action research process.
Although the purpose of action research is to promote change, in some studies, the impact is not clearly reflected in the results section.

AUTH O R CO NTR I B UTI O N S
Made substantial contributions to conception and design, acquisition

FUNDING INFORMATION
None.

CO N FLI C T O F I NTE R E S T
None.

PEER R E V I E W
The peer review history for this article is available at https://publo ns.com/publo n/10.1111/jan.15463.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.